A 68‐year‐old man who has been having dizzy spells over the last few months is referred to you. He has not lost consciousness but the dizzy spells are becoming more frequent, particularly if he exerts himself. He has a history of angina for which he uses a glyceryl trinitrate (GTN) spray and takes atenolol 50 mg od. He also has hypercholestrolaemia and has had a transurethral resection of his prostate in the past. On examination he has several xanthalasma around the eyes and corneal arcus, but no splinter haemorrhages. Neurological examination is normal.

BP is 110/70 mmHg, pulse is slow rising pulse, rate 56 beats/min, sinus rhythm. The apex beat is non‐displaced and clearly palpable. He has a systolic murmur which radiates across the praecordium and also to the carotids (Fig. 0001). Chest sounds are clear and chest X‐ray appears normal.

Fig. 0001.